| 1 | archetype (adl_version=1.4)
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| 2 | openEHR-EHR-CLUSTER.exam-uterine_cervix.v1
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| 3 | specialize
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| 4 | openEHR-EHR-CLUSTER.exam.v1
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| 5 |
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| 6 | concept
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| 7 | [at0000.1] -- Examination of the cervix
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| 8 | language
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| 9 | original_language = <[ISO_639-1::en]>
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| 10 | description
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| 11 | original_author = <
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| 12 | ["name"] = <"unknown">
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| 13 | >
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| 14 | details = <
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| 15 | ["en"] = <
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| 16 | language = <[ISO_639-1::en]>
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| 17 | purpose = <"A cluster for recording findings regarding the uterine cervix on physical examination.">
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| 18 | use = <"">
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| 19 | keywords = <"examination", "physical", "cervix", "uterine">
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| 20 | misuse = <"">
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| 21 | >
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| 22 | >
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| 23 | lifecycle_state = <"Initial">
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| 24 | other_contributors = <>
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| 25 |
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| 26 | definition
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| 27 | CLUSTER[at0000.1] matches { -- Examination of the cervix
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| 28 | items cardinality matches {0..*; unordered} matches {
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| 29 | CLUSTER[at0004] occurrences matches {0..1} matches { -- Normal statements
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| 30 | items cardinality matches {0..*; unordered} matches {
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| 31 | ELEMENT[at0005] occurrences matches {0..*} matches { -- Normal statement
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| 32 | value matches {
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| 33 | DV_TEXT matches {*}
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| 34 | }
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| 35 | }
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| 36 | }
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| 37 | }
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| 38 | ELEMENT[at0002] occurrences matches {0..1} matches { -- Clinical description
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| 39 | value matches {
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| 40 | DV_TEXT matches {*}
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| 41 | }
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| 42 | }
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| 43 | CLUSTER[at0008] occurrences matches {0..1} matches { -- Findings
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| 44 | items cardinality matches {0..*; unordered} matches {
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| 45 | ELEMENT[at0.8] occurrences matches {0..1} matches { -- Position
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| 46 | value matches {
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| 47 | DV_CODED_TEXT matches {
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| 48 | defining_code matches {
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| 49 | [local::
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| 50 | at0.9, -- Central
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| 51 | at0.10, -- To the right
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| 52 | at0.11, -- To the left
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| 53 | at0.12, -- Anterior
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| 54 | at0.13] -- Posterior
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| 55 | }
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| 56 | }
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| 57 | }
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| 58 | }
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| 59 | ELEMENT[at0.36] occurrences matches {0..1} matches { -- Consistency
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| 60 | value matches {
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| 61 | DV_CODED_TEXT matches {
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| 62 | defining_code matches {
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| 63 | [local::
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| 64 | at0.37, -- Soft
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| 65 | at0.38] -- Firm
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| 66 | }
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| 67 | }
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| 68 | }
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| 69 | }
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| 70 | CLUSTER[at0007] occurrences matches {0..1} matches { -- Size
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| 71 | items cardinality matches {0..*; unordered} matches {
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| 72 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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| 73 | include
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| 74 | archetype_id/value matches {/dimensions\.v1/}
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| 75 | }
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| 76 | }
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| 77 | }
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| 78 | CLUSTER[at0.48] occurrences matches {0..1} matches { -- Labour-specific findings
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| 79 | items cardinality matches {0..*; unordered} matches {
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| 80 | ELEMENT[at0.14] occurrences matches {0..1} matches { -- Effacement
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| 81 | value matches {
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| 82 | 0|[local::at0.15], -- Uneffaced
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| 83 | 5|[local::at0.26], -- Ripe
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| 84 | 10|[local::at0.16], -- 10% effaced
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| 85 | 20|[local::at0.17], -- 20% effaced
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| 86 | 30|[local::at0.18], -- 30% effaced
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| 87 | 40|[local::at0.19], -- 40% effaced
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| 88 | 50|[local::at0.20], -- Partially (50%) effaced
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| 89 | 60|[local::at0.21], -- 60% effaced
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| 90 | 70|[local::at0.22], -- 70% effaced
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| 91 | 80|[local::at0.23], -- 80% effaced
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| 92 | 90|[local::at0.24], -- 90% effaced
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| 93 | 100|[local::at0.25] -- Fully effaced
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| 94 | }
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| 95 | }
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| 96 | ELEMENT[at0.40] occurrences matches {0..1} matches { -- Thickness
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| 97 | value matches {
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| 98 | DV_CODED_TEXT matches {
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| 99 | defining_code matches {
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| 100 | [local::
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| 101 | at0.41, -- Thick
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| 102 | at0.42, -- Thin
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| 103 | at0.43, -- Paper-thin
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| 104 | at0.44] -- Oedematous
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| 105 | }
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| 106 | }
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| 107 | }
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| 108 | }
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| 109 | ELEMENT[at0.45] occurrences matches {0..1} matches { -- Application to presenting part
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| 110 | value matches {
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| 111 | DV_CODED_TEXT matches {
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| 112 | defining_code matches {
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| 113 | [local::
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| 114 | at0.46, -- Loosely applied
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| 115 | at0.47] -- Tightly applied
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| 116 | }
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| 117 | }
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| 118 | }
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| 119 | }
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| 120 | CLUSTER[at0.27] occurrences matches {0..2} matches { -- Cervical os
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| 121 | items cardinality matches {0..*; unordered} matches {
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| 122 | ELEMENT[at0.32] occurrences matches {0..1} matches { -- Site
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| 123 | value matches {
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| 124 | DV_CODED_TEXT matches {
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| 125 | defining_code matches {
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| 126 | [local::
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| 127 | at0.33, -- External os
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| 128 | at0.34] -- Internal os
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| 129 | }
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| 130 | }
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| 131 | }
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| 132 | }
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| 133 | CLUSTER[at0.31] occurrences matches {0..1} matches { -- Dilation
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| 134 | items cardinality matches {0..*; unordered} matches {
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| 135 | ELEMENT[at0.28] occurrences matches {0..1} matches { -- Estimate
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| 136 | value matches {
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| 137 | C_DV_QUANTITY <
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| 138 | property = <[openehr::122]>
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| 139 | list = <
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| 140 | ["1"] = <
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| 141 | units = <"cm">
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| 142 | magnitude = <|0.0..10.0|>
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| 143 | precision = <|1|>
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| 144 | >
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| 145 | >
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| 146 | >
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| 147 | }
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| 148 | }
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| 149 | ELEMENT[at0.35] occurrences matches {0..1} matches { -- Number of finger tips admitted
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| 150 | value matches {
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| 151 | DV_COUNT matches {*}
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| 152 | }
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| 153 | }
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| 154 | }
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| 155 | }
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| 156 | ELEMENT[at0.29] occurrences matches {0..1} matches { -- Findings
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| 157 | value matches {
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| 158 | DV_TEXT matches {*}
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| 159 | }
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| 160 | }
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| 161 | }
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| 162 | }
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| 163 | }
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| 164 | }
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| 165 | allow_archetype CLUSTER occurrences matches {0..*} matches {
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| 166 | include
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| 167 | archetype_id/value matches {/palpation\.v1draft/}
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| 168 | archetype_id/value matches {/inspection\.v1draft/}
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| 169 | exclude
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| 170 | archetype_id/value matches {/.*/}
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| 171 | }
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| 172 | CLUSTER[at0.30] occurrences matches {0..1} matches { -- Vaginal fluid
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| 173 | items cardinality matches {0..*; unordered} matches {
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| 174 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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| 175 | include
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| 176 | archetype_id/value matches {/fluid\.v1/}
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| 177 | }
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| 178 | }
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| 179 | }
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| 180 | CLUSTER[at0003] occurrences matches {0..1} matches { -- Detail
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| 181 | items cardinality matches {0..*; unordered} matches {
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| 182 | allow_archetype CLUSTER occurrences matches {0..1} matches {
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| 183 | include
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| 184 | archetype_id/value matches {/exam\.v1/}
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| 185 | archetype_id/value matches {/exam-fetus\.v1/}
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| 186 | }
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| 187 | }
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| 188 | }
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| 189 | }
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| 190 | }
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| 191 | ELEMENT[at0006] occurrences matches {0..*} matches { -- Image
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| 192 | value matches {
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| 193 | DV_MULTIMEDIA matches {
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| 194 | media_type matches {
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| 195 | [openEHR::
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| 196 | 426,
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| 197 | 427,
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| 198 | 429]
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| 199 | }
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| 200 | }
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| 201 | }
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| 202 | }
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| 203 | }
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| 204 | }
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| 205 |
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| 206 | ontology
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| 207 | term_definitions = <
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| 208 | ["en"] = <
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| 209 | items = <
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| 210 | ["at0.1"] = <
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| 211 | description = <"Information about the size of the object for examination">
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| 212 | text = <"Size">
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| 213 | >
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| 214 | ["at0.10"] = <
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| 215 | description = <"The cervix is deviated to the right">
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| 216 | text = <"To the right">
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| 217 | >
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| 218 | ["at0.11"] = <
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| 219 | description = <"The cervix is deviated to the left">
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| 220 | text = <"To the left">
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| 221 | >
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| 222 | ["at0.12"] = <
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| 223 | description = <"The cervix is anterior near the pubis">
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| 224 | text = <"Anterior">
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| 225 | >
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| 226 | ["at0.13"] = <
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| 227 | description = <"The cervix is at the back near the sacrum">
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| 228 | text = <"Posterior">
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| 229 | >
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| 230 | ["at0.14"] = <
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| 231 | description = <"The effacement of the uterine cervix in late pregnancy or labour.">
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| 232 | text = <"Effacement">
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| 233 | >
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| 234 | ["at0.15"] = <
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| 235 | description = <"The cervix has not changed its form">
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| 236 | text = <"Uneffaced">
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| 237 | >
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| 238 | ["at0.16"] = <
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| 239 | description = <"The cervix is effaced to about 10%">
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| 240 | text = <"10% effaced">
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| 241 | >
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| 242 | ["at0.17"] = <
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| 243 | description = <"The cervix is effaced to about 20%">
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| 244 | text = <"20% effaced">
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| 245 | >
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| 246 | ["at0.18"] = <
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| 247 | description = <"The cervix is effaced to about 30%">
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| 248 | text = <"30% effaced">
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| 249 | >
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| 250 | ["at0.19"] = <
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| 251 | description = <"The cervix is effaced to about 40%">
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| 252 | text = <"40% effaced">
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| 253 | >
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| 254 | ["at0.20"] = <
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| 255 | description = <"The cervix is partially effaced to about 50%">
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| 256 | text = <"Partially (50%) effaced">
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| 257 | >
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| 258 | ["at0.21"] = <
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| 259 | description = <"The cervix is effaced to about 60%">
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| 260 | text = <"60% effaced">
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| 261 | >
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| 262 | ["at0.22"] = <
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| 263 | description = <"The cervix is effaced to about 70%">
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| 264 | text = <"70% effaced">
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| 265 | >
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| 266 | ["at0.23"] = <
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| 267 | description = <"The cervix is effaced to about 80%">
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| 268 | text = <"80% effaced">
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| 269 | >
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| 270 | ["at0.24"] = <
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| 271 | description = <"The cervix is effaced to about 90%">
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| 272 | text = <"90% effaced">
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| 273 | >
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| 274 | ["at0.25"] = <
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| 275 | description = <"The cervix is fully effaced to 100%">
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| 276 | text = <"Fully effaced">
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| 277 | >
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| 278 | ["at0.26"] = <
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| 279 | description = <"The cervix is ripe and beginning to efface">
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| 280 | text = <"Ripe">
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| 281 | >
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| 282 | ["at0.27"] = <
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| 283 | description = <"The outlet of the uterus">
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| 284 | text = <"Cervical os">
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| 285 | >
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| 286 | ["at0.28"] = <
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| 287 | description = <"The dilation of the os">
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| 288 | text = <"Estimate">
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| 289 | >
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| 290 | ["at0.29"] = <
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| 291 | description = <"Findings about the cervical os">
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| 292 | text = <"Findings">
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| 293 | >
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| 294 | ["at0.30"] = <
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| 295 | description = <"Vaginal loss or discharge">
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| 296 | text = <"Vaginal fluid">
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| 297 | >
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| 298 | ["at0.31"] = <
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| 299 | description = <"Dilation of cervix">
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| 300 | text = <"Dilation">
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| 301 | >
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| 302 | ["at0.32"] = <
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| 303 | description = <"Identify part of cervix which is being examined">
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| 304 | text = <"Site">
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| 305 | >
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| 306 | ["at0.33"] = <
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| 307 | description = <"External opening of the cervix to the vagina">
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| 308 | text = <"External os">
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| 309 | >
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| 310 | ["at0.34"] = <
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| 311 | description = <"Internal opening of the cervix to the uterus">
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| 312 | text = <"Internal os">
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| 313 | >
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| 314 | ["at0.35"] = <
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| 315 | description = <"Number of finger tips that are able to be admitted into the internal or external os">
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| 316 | text = <"Number of finger tips admitted">
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| 317 | >
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| 318 | ["at0.36"] = <
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| 319 | description = <"Consistency of cervix">
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| 320 | text = <"Consistency">
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| 321 | >
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| 322 | ["at0.37"] = <
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| 323 | description = <"Soft">
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| 324 | text = <"Soft">
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| 325 | >
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| 326 | ["at0.38"] = <
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| 327 | description = <"Firm">
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| 328 | text = <"Firm">
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| 329 | >
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| 330 | ["at0.39"] = <
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| 331 | description = <"Length of cervix">
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| 332 | text = <"Length">
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| 333 | >
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| 334 | ["at0.40"] = <
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| 335 | description = <"Cervical thickness">
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| 336 | text = <"Thickness">
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| 337 | >
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| 338 | ["at0.41"] = <
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| 339 | description = <"Thick">
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| 340 | text = <"Thick">
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| 341 | >
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| 342 | ["at0.42"] = <
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| 343 | description = <"Thin">
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| 344 | text = <"Thin">
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| 345 | >
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| 346 | ["at0.43"] = <
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| 347 | description = <"Very thin">
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| 348 | text = <"Paper-thin">
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| 349 | >
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| 350 | ["at0.44"] = <
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| 351 | description = <"Thickened and swollen">
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| 352 | text = <"Oedematous">
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| 353 | >
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| 354 | ["at0.45"] = <
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| 355 | description = <"Application of cervix to fetal presenting part">
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| 356 | text = <"Application to presenting part">
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| 357 | >
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| 358 | ["at0.46"] = <
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| 359 | description = <"Not moulded to presenting part">
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| 360 | text = <"Loosely applied">
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| 361 | >
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| 362 | ["at0.47"] = <
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| 363 | description = <"Moulded to presenting part">
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| 364 | text = <"Tightly applied">
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| 365 | >
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| 366 | ["at0.48"] = <
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| 367 | description = <"*">
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| 368 | text = <"Labour-specific findings">
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| 369 | >
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| 370 | ["at0.8"] = <
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| 371 | description = <"The position in relation to the normal anatomical position">
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| 372 | text = <"Position">
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| 373 | >
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| 374 | ["at0.9"] = <
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| 375 | description = <"The cervix is central and in the normal position">
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| 376 | text = <"Central">
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| 377 | >
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| 378 | ["at0000"] = <
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| 379 | description = <"Generic examination cluster for describing a finding on physical examination">
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| 380 | text = <"Examination">
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| 381 | >
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| 382 | ["at0000.1"] = <
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| 383 | description = <"Examination findings on physical examination of the uterine cervix">
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| 384 | text = <"Examination of the cervix">
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| 385 | >
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| 386 | ["at0001"] = <
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| 387 | description = <"The object of the examination">
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| 388 | text = <"Object">
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| 389 | >
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| 390 | ["at0002"] = <
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| 391 | description = <"Textural description of the part examined">
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| 392 | text = <"Clinical description">
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| 393 | >
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| 394 | ["at0003"] = <
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| 395 | description = <"More focused examination findings">
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| 396 | text = <"Detail">
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| 397 | >
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| 398 | ["at0004"] = <
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| 399 | description = <"A group of statements about the normality of the examination">
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| 400 | text = <"Normal statements">
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| 401 | >
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| 402 | ["at0005"] = <
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| 403 | description = <"A specific statement of normality">
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| 404 | text = <"Normal statement">
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| 405 | >
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| 406 | ["at0006"] = <
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| 407 | description = <"Drawing or image of the area examined">
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| 408 | text = <"Image">
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| 409 | >
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| 410 | ["at0007"] = <
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| 411 | description = <"Information about the size of the object for examination">
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| 412 | text = <"Size">
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| 413 | >
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| 414 | ["at0008"] = <
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| 415 | description = <"Clinical findings">
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| 416 | text = <"Findings">
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| 417 | >
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| 418 | >
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| 419 | >
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| 420 | >
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